LDL-C goal Attainment Among Patients Newly Diagnosed With Coronary Heart Disease or Diabetes in a Commercial HMO

BACKGROUND: Patients beginning treatment with lipid-modifying drugs should have their serum lipid levels monitored and, if necessary, their drug therapy adjusted to reach and maintain their treatment goals. Patients with coronary heart disease or diabetes are at high risk of coronary events and are particularly important target groups for monitoring and dose adjustment of lipid-modifying drug therapy. OBJECTIVES: to determine from administrative claims the rates of lipid testing,treatment with low-density lipoprotein cholesterol (LdL-c)-lowering drug therapy, and LdL-c goal attainment defined as LdL-c less than 100 mg per dL in the time period after a new diagnosis of coronary heart disease or diabetes among patients who had not previously received lipid-modifying drug therapy. METHODS: an index date was defined by a new diagnosis of coronary heart disease or diabetes between January 1, 1999 and December 31, 2000,preceded by a 12-month pre-index period without lipid-modifying drug treatment in a commercial health maintenance organization (hMo) database for the southeastern united states. coronary heart disease (chd) was defined by a diagnosis code for myocardial infarction (International Classification of Diseases, Ninth Edition, Clinical Modification [icd-9-cM] code 410.xx) orangina/ischemic heart disease (411.xx), or a procedural code for angioplasty(icd-9-cM 36.1x-36.3x; Current Procedural Terminology [cPt] 92980-92984,92995-92996) or coronary artery bypass graft (icd-9-cM 36.01, 36.02, 36.05,36.09; cPt 33510-33545). diabetes was identified either by an icd-9-cM diagnosis code 250.xx or a pharmacy claim for an anti-hyperglycemic medication. Patients were followed in the post-index period until loss of eligibility or a maximum of 42 months (mean = 26 months, range=12-42 months). We calculated the proportion of patients with lipids treated and atLdL-c goal (defined as LdL-c less than 100 mg per dL) in months 1-6 after the index date. among those not at goal in months 1-6, we estimated the proportion treated to goal in months 7-12 and in month 7 to the end of the post-index period. Logistic regression was used to estimate the odds of goal attain mentin months 7-12 and in month 7 to the end of the post-index period among patients who were not at goal in months 1-6. RESULTS: Laboratory lipid values were available for 4,676 (40.4%) of 11,552 patients who had not previously received lipid-modifying drug therapy in months 1-6 after the index date, of whom 72.7% (n=3,400) had an LdL-c≥100 mg per dL (63.5% for chd and 76.7% for diabetes). of 1,245 patients tested and treated with lipid-modifying therapy in months 1-6, 485 (39.0%) were at LdL-c goal in months 1-6 (48.2% of chd and 28.8% of diabetes patients), and 760 (61.0%) were not at LdL-c goal (51.8% of those with chd and 71.2% of those with diabetes). goal attainment (cumulative) among those treated improved to 50.1% in months 7-12 and 58.4% in month 7 to the end of the post-index period. Patients not attaining goal in months 1-6, and who continued treatment in months 7-12 and month 13 to the end of the post-index period, had a 48.8% (95% confidence interval [ci], 44.0%-53.6%) predicted probability of attaining their goals. The odds of goal attainment in month 7 to the end of post-index period (among those not at goal in months 1-6) were greater for (a) age≥65 years (odds ratio [or]=2.45, 95% ci, 1.62-3.72), (b)history of hypertension (or=1.91, 95% ci, 1.20-3.03), (c) greater number of distinct medications (or=1.07, 95% ci, 1.01-1.14 per additional medication),(d) months of observation post-index (or=1.04, 95% ci=1.01-1.08 per additional month), and (e) months supply of lipid-modifying medication(or = 1.04, 95% ci, 1.01-1.07 per additional month), and were lower for LdL-c≥130 mg per dL in months 1-6 (or=0.53, 95% ci, 0.35-0.82) and a history of dyslipidemia (or=0.54, 95% ci, 0.35-0.83). the odds of LdL-c goal attainment were not affected by diagnosis (chd vs. diabetes), gender, statin titration (34% of patients), lipid-modifying drug switching (39% of patients), or treatment with a high-potency LdL-c-lowering drug dosage (one of sufficient strength to reduce LdL-c by greater than 40%).Conclusion: of patients receiving lipid testing and lipid drug treatment in the 6 months after an initial diagnosis of chd or diabetes, 61% were not at the LdL-c goal of less than 100 mg per dL. Among those not at LdL-c goal in the first6 months of treatment, only about half who continued treatment subsequent ly attained their LdL-c goal, despite statin titration or switching of their lipid modifying drug therapy.


What is already known about this subject
What this study adds • The LDL-C goal attainment rate for a national sample of patients with coronary heart disease (CHD) in 2003 was 62%. • National surveys and cross-sectional studies of diabetic patients in managed care reported a lipid-modifying drug treatment rate of 28% in 1999-2000 and LDL-C goal (<100 mg per dL) attainment rates of 32-55% in 1999-2003. The 2003 Healthcare Effectiveness Data and Information Set (HEDIS) average LDL-C goal (<100 mg per dL) attainment rate for diabetes in participating commercial health plans was 35%, which improved to 44% in 2005. • While these cross-sectional studies provide snapshots of lipid management at points in time, not enough is known about the rates of LDL-C goal attainment in the months after first diagnosis of CHD or diabetes.
• Of those who weret ested and treated for LDL-C in the first 6 months after an initial diagnosis of CHD or diabetes, 39.0% (CHD 48%, diabetes 29%) wereatLDL-C goal <100 mg per dL. • Cumulative goal attainment among those continuing treatment improved to 50% in the second 6 months and to 58% over 26 months of follow-up. • Patients who weret reated but not at LDL-C <100 mg per dL in the first 6m onths after diagnosis and who continued treatment with lipid-modifying drugs had only about a50% probability of subsequently attaining LDL-C goal regardless of CHD or diabetes diagnosis.

LDL-C Goal Attainment Among Patients Newly Diagnosed With Coronary Heart Disease or Diabetes in aCommercial HMO
B oth the National Cholesterol Education Program (NCEP) and the American Diabetes Association (ADA) guidelines now recommend treating patients with coronary heart disease (CHD) or diabetes to al ow-density lipoproteincholesterol (LDL-C) goal of <1 00 mg per dL. 1,2 The goal of LDL-C <1 00 mg per dL was first defined for CHD in 1994 by the NCEP Adult Treatment Panel II (ATP II), and for diabetes by the ADA in 1998. 3,4 The NCEP ThirdA dult Treatment Panel (ATP III) in 2001 assigned diabetes CHD risk equivalence, and an LDL-C goal of <1 00 mg per dL was adopted. 1 Despite the guidelines, therei sc onsiderable evidence of inadequate LDL-C goal attainment in clinical practice. [5][6][7][8][9][10][11][12][13][14][15][16][17][18] Nationwide in 2003, LDL-C goal attainment was 57% for patients with CHD, diabetes, or CHD risk equivalence, compared with 89% for patients in the zeroCHD risk factor category. 18 Thereis, however,little information about the likelihood of attaining LDL-C goal in the months immediately after CHD or diabetes diagnosis.
In this study,L DL-C goal attainment in the months after diagnosis of CHD or diabetes (diagnosis by medical claim code or pharmacy claim for an anti-hyperglycemic drug) in patients beginning treatment with lipid-modifying drugs was examined.

Study design and patient selection
This was aretrospective cohort study using administrative claims data in the HealthCoreI ntegrated Research Database for the period January1 ,1 998 through June 30, 2002. The data set used was from the commercial health maintenance organization (HMO) portion of as outheasternU nited States managed care organization (MCO). Electronic records of laboratoryv alues wereo btained from as ingle national laboratoryp rovider under contract to this HMO. The initial study database included data for approximately 1.1 million members in which all MCO eligibility,m edical, and pharmacy files werel inked by member identification number to electronic records of laboratoryv alues from the single national provider.The database did not include laboratoryt ests conducted in inpatient or outpatient hospital settings or in physician offices (i.e., the laboratoryv alues were missing from the database for any facility or physician that did not outsource testing to the single national laboratoryprovider).
Patients' identities werem asked throughout the study in al imited data set format, in accordance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Institutional review boardapproval was not sought, because there was no patient intervention and the limited data wereutilized in accordance with appropriate data use agreements with the covered entities as defined in HIPAA.
The index date was defined as the date of the first claim with ad iagnosis or procedurec ode for CHD, ad iagnosis code for diabetes, or ap harmacy claim for an anti-hyperglycemic drug. Continuous plan eligibility was required for at least 12 months beforea nd after the index date (the 12-month pre-index and post-index periods). Patients weree xcluded if they had an encounter claim coded with CHD or diabetes, or if they received al ipid-lowering medication, during the 12-month pre-index period. Since the goal of this study was to examine LDL-C goal attainment following an incident diagnosis of CHD or diabetes among patients previously untreated with lipid-modifying medications, al ipid-lowering medication in the pre-index period was acriterion for exclusion. Adiagnosis of dyslipidemia was not areason for exclusion, provided therewas no evidence of lipid-modifying drug treatment. Dyslipidemia was regarded as ap otentially confounding variable and it was included as a covariate in the regression model.
Only patients with electronic laboratorydata available in the HealthCoreI ntegrated Research Database in the 12-month pre-index and post-index periods werer etained for further analysis. Sixty-one patients with initial diagnoses for both CHD and diabetes on the index date (i.e., on the same day) weree xcluded as potentially spurious data. The sample selection steps ares hown in Figure1 ,a nd the study periods are illustrated in Figure2.

Study variables
Lipid testing, treatment, and LDL-C goal attainment were each determined within 3t ime periods after the index date: months 1-6, months 7-12, and month 7t ot he end of the post-index period (Figure2 ). LDL-C testing was determined by the presence of 1o rm oreL DL-C or lipid panel values in the electronic database of laboratoryr esults. These values were recorded using either Logical Observation Identifiers Names and Codes (LOINC) or actual test names. The laboratoryrecords included the date of testing. LDL-C values werec alculated using the Friedewald formula, which computes LDL-C from the equation: TC -HDL-C -TG/5, whereT C, HDL-C, and TG aret he plasma concentrations of total cholesterol, high-density lipoprotein-cholesterol, and triglycerides, respectively, 19 or obtained directly if triglycerides were> 400 mg per dL. (The Friedewald formula is unable to calculate LDL-C for patients whose triglycerides exceed 400 mg/dL.) LDL-C goal attainment was defined as LDL-C <100 mg per dL. The lowest LDL C value was used for patients with more than 1 LDL-C measurement within any of the post-index time periods.
Use of lipid-lowering medication was determined from pharmacy claims with GPI-4 codes 3940, 3910, 3920, and 3945 for 3-hydroxy-3-methyl-glutaryl-CoA (HMG-CoA) reductase inhibitors ("statins"), bile acid sequestrants, fibric acid derivatives, and nicotinic acid derivatives, respectively. Patients were considered to be on lipid-lowering therapy during months 1-6 after the index date if they had at least 1 pharmacy claim for any lipid-modifying medication during that time period. For patients who were not at LDL-C goal in months 1-6 and who continued drug treatment, we examined LDL-C goal attainment in months 7-12 and in month 7 to the end of the post-index period. Patients were defined as treated during months 7-12 if they received at least 1 pharmacy claim for any lipid-modifying medication in months 1-6 and in months 7-12. Patients were defined as treated from month 7 to the end of the post-index period if they received at least 1 pharmacy claim for any lipidmodifying medication in each of the 3 following time periods: months 1-6, months 7-12, and month 13 to the end of the postindex period. Table 1 summarizes the identification of patients whose lipids were tested and who were treated with lipid-modifying drugs.
High-potency LDL-C treatment was defined as a lipid-lowering drug dosage of sufficient strength to reduce LDL-C by > 40%, which included simvastatin 40 mg or higher, atorvastatin 20 mg or higher, or rosuvastatin 10 mg or higher. History of hypertension (ICD-9-CM 401.xx and a pharmacy claim for an antihypertensive medication) and dyslipidemia (ICD-9-CM 272. xx) were determined during the 12-month pre-index period.

LDL-C Goal Attainment Among Patients Newly Diagnosed With Coronary Heart Disease or Diabetes in a Commercial HMO
at the drug class level from the number of unique 2-character GPI codes for all drugs, including both acute and chronic medications (e.g., 01 for penicillins; 02 for cephalosporins; 33 for beta-blockers; 34 for calcium channel blockers; and 36 for angiotensin-converting enzyme [ACE] inhibitors, angiotensin II receptor blocker [ARBs], and other antihpertensives) during the 12-month pre-index period.

Statistical methods
The characteristics of patients newly diagnosed with CHD and diabetes were compared using descriptive statistics. The statistical significance of differences between these 2 patient sets was determined using an independent t test for continuous variables and Pearson chi-square tests for nominal/categorical variables. Rates of lipid treatment and LDL-C goal attainment in months 1-6 were examined with descriptive analyses. We applied logistic regression to estimate the odds of LDL-C goal attainment in months 7-12 and from month 7 to the end of the post-index period among patients who did not attain LDL-C goal in months 1-6. The outcome for each model was binary, with attaining the LDL-C goal set to 1 and not attaining the goal set to 0. Odds ratios for all model covariates were calculated by exponentiating the logistic regression coefficients. The sample used for model estimation was limited to patients with LDL-C, HDL-C, and triglyceride measurements in months 1-6. Variables entered into the models were chosen a priori based on clinical relevance and forced into the final models regardless of statistical significance. These variables included age, sex, histories of hypertension and dyslipidemia, CHD or diabetes status, lipid values (LDL-C ≥ 130 mg per dL, HDL-C < 40 mg per dL, and triglycerides ≥ 200 mg per dL) in months 1-6, adjustments to lipid therapy (statin titration, switching), use of high-potency LDL-lowering statin dosages, the number of days supply of lipid-modifying drugs, and the number of distinct prescription medications. The number of distinct prescription medications is an adjustment for comorbidity burden that has been validated. 20,21 Regression model fit was assessed using the Hosmer-Lemeshow goodness-of-fit test and discrimination was measured by examining the area under the ROC curve. 22 To calculate overall predicted probability of goal attainment, mean values on all covariates were calculated and inserted into the logistic regression equation (i.e., multiplied by the logistic regression coefficients). 23 As is standard in logistic regression, the resulting linear predictor (natural log of the odds) was converted into an overall probability using the formula: e Z / (1+ e Z ), where e is the base of natural logarithms and Z is the linear predictor.This calculation was performed for the sample overall and for each of the 2patient sets (CHD and diabetes).
Statin titration was defined as an increase in the strength of the dispensed statin. As witch was defined as ac laim for any lipid drug (statin or nonstatin) different from the previous lipid drug fill, with no subsequent claim for the original drug. For the regression model that predicted LDL-C goal attainment in months 7-12, the titration and switching variables were determined for months 1-12. For the model that predicted goal attainment in month 7tothe end of the post-index period, the titration and switching variables wered etermined for month 1t ot he end of the post-index period. The number of months in the post-index period was included in the model for goal attainment in month 7t ot he end of the post-index period, to adjust for unequal duration of follow-up among patients.
The number of days supply was aggregated for all statins. As mall fraction of patients weret reated only with nonstatins (5.9% of patients in months 1-6; 4.5% of patients in months 7-12; and 3.6% of patients in month 7t ot he end of the study period). Since days supply was not captured for patients treated only with nonstatins, it was imputed based on an adjusted days

LDL-C Goal Attainment Among Patients Newly Diagnosed With Coronary Heart Disease or Diabetes in a Commercial HMO
where e is the base of natural logarithms and Z is the linear predictor. This calculation was performed for the sample overall and for each of the 2 patient sets (CHD and diabetes).
Statin titration was defined as an increase in the strength of the dispensed statin. A switch was defined as a claim for any lipid drug (statin or nonstatin) different from the previous lipid drug fill, with no subsequent claim for the original drug. For the regression model that predicted LDL-C goal attainment in months 7-12, the titration and switching variables were determined for months 1-12. For the model that predicted goal attainment in month 7 to the end of the post-index period, the titration and switching variables were determined for month 1 to the end of the post-index period. The number of months in the post-index period was included in the model for goal attainment in month 7 to the end of the post-index period, to adjust for unequal duration of follow-up among patients.
The number of days supply was aggregated for all statins. A small fraction of patients were treated only with nonstatins (5.9% of patients in months 1-6; 4.5% of patients in months 7-12; and 3.6% of patients in month 7 to the end of the study period). Since days supply was not captured for patients treated only with nonstatins, it was imputed based on an adjusted days

LDL-C Goal Attainment Among Patients Newly Diagnosed With Coronary Heart Disease or Diabetes in aCommercial HMO
supply for statins. An ordinaryl east squares regression model was run for statin users who werenot at goal in months 1-6: days supply = β 0+β 1(CHD vs. diabetes)+ β 2(age) + β 3(sex)+ ε .The model estimates werethen used to predict days supply for nonstatin users. Separate regressions estimated the days supply for months 1-12 and for the entirepost-index period. The observed days supply for the statin users and the imputed days supply for the nonstatin users weret hen entered (as months supply) into the regression models of LDL-C goal attainment. An apriori 2-tailed level of significance was set at the 0.05 level. All analyses werecarried out using Stata version 8.2 (Stata Corporation, Inc., College Station, TX).

nn RESULTS
Most of the 11,522 patients who met the study inclusion criteria werenewly diagnosed with diabetes (71%), the remaining 29% being newly diagnosed with CHD. Compared with patients with diabetes, those with CHD weresignificantly older and included ahigher proportion of males ( Table 2). The duration of the postindex period was similar for both cohorts, with an overall mean of 26 months (range 12-42 months). The proportions of patients with histories of hypertension and dyslipidemia werehigher for patients with newly diagnosed CHD than for those with diabetes (38% vs. 32% and 28% vs. 23%, respectively). Mean LDL-C levels in the 12-month pre-index period wereslightly higher for CHD patients, whereas median triglyceride levels weres ignificantly higher for patients with diabetes.
The days of supply of lipid-modifying drugs arepresented in Table 3. For all patients, the mean days supply represented approximately two-thirds of days in months 1-6 (114 of 180 days) and months 1-12 (224 of 360 days). The mean numbers of days supply weregreater for patients with CHD than for patients with diabetes in months 1-6 (126 vs. 101 days) months 1-12 (236 vs. 214 days), and overall (542 vs. 466 days).
The multivariate analyses showed that among patients who did not attain LDL-C goal in months 1-6 and who continued to be treated, therew as no significant difference in goal attainment between CHD and diabetes patients in months 7-12 or in month 7tothe end of the post-index period (

nn DISCUSSION
In this study,w ee xamined the course of lipid management and LDL-C goal attainment for an average of 26 months after an ew diagnosis of CHD or diabetes in am anaged cares etting. Patients who weret reated with lipid-modifying drugs but who did not attain LDL-C goal in months 1-6 had only about a1in2 predicted probability (48.8%) of goal attainment in months 7to the end of the post-index period, regardless of CHD or diabetes diagnosis. Thereh ave been few longitudinal studies of rates of lipid testing, lipid drug treatment, and LDL-C goal attainment among patients with diabetes or CHD in the period since publication of the 1994 ATPI Ia nd 1998 ADA guidelines, which first advocated the LDL-C standardo f<100 mg per dL for CHD and diabetes, respectively. 3,4 Beaton et al. reported an LDL-C testing rate of 54% and al ipid-lowering drug treatment rate of 28% for patients with diabetes in managed carein1999-2000. 8 Reported rates of LDL-C goal attainment (< 100 mg per dL) were6 2% for patients with CHD in 2003 18,24 and 32%-55% for patients with diabetes in 1999-2003. [8][9][10]18 These studies werea ll cross-sectional and included national surveys. 18,24 The National Committee for Quality Assurance has reported rates of LDL-C testing and goal attainment in participating US managed  25 The HEDIS rate of LDL-C < 100 mg per dL for diabetes in commercial plans was 35%-44% in 2003-2005. 25 The corresponding rate for LDL-C < 130 mg per dL was 29%-55% in 1999-2002 and 60%-68% in 2003-2005. 25 There have been few longitudinal studies of patients with CHD or diabetes. Retrospective cohort studies have focused on patients with hyperlipidemia 15,26 and patients treated with lipid-modifying drugs, 27 or specifically with statins (during 1997-2004) [28][29][30][31] although there have been some retrospective cohort studies of high-risk patient groups (during 1996-2001). 16,17,32 Many of these studies focused on adherence to drug therapy. 28,29,31,32 Stacy and Egger reported that treatment with lipid-modifying drugs increased LDL-C goal attainment from 23% at baseline (prior to any drug treatment) to 68% over an average of 3.7 years later (in 2004). 26 These patients had hyperlipidemia and/or hypercholesterolemia, however, rather than CHD or diabetes, and were treated by high-volume prescribers, so that most patients (84%) had received at least 1 lipid-modifying medication. 26 Valuck et al. and Meyer et al. reported that patients treated with high-potency statin regimens were significantly more likely to attain an LDL-C goal < 100 mg per dL than patients treated with non-high-potency regimens. 17,27 In the present study, fewer patients with a new diagnosis of diabetes received lipid-modifying medication or attained the LDL-C goal of < 100 mg per dL than did newly diagnosed CHD patients. There are several reasons why this may have occurred. First, diabetes patients may have received less intensive LDL-C testing and treatment, because the focus in newly diagnosed diabetes patients is often on control of blood glucose. Second, since our definition of CHD included conditions likely to require urgent medical care and/or hospitalization (e.g., myocardial infarction, angioplasty, coronary artery bypass graft), newly diagnosed CHD patients may have been perceived as needing more aggressive therapy. Finally, the data for this study were recorded between January 1, 1998 and June 30,2002 and, although the ADA guidelines have recommended an LDL-C goal of <1 00 mg per dL for diabetes since 1998, the NCEP ATPIIand HEDIS standardwas LDL-C <130 mg per dL.
nn Limitations Foremost among the study limitations is the uncertainty about which was the prevailing standardf or LDL-C goal attainment for patients with diabetes during the study period. The ATPI IL DL-C goal for CHD was <100 mg/dL throughout our study period, as was the ADA goal for LDL-C in patients with diabetes. The formal release of the NCEP ATPIII guidelines, which swept all diabetes patients regardless of CHD status into the new LDL goal of <100 mg per dL, occurred after our study period, although the executive summaryo ft he new ATPI II guideline appeared in May 2001, in the last year of our post-index period.
In addition, the HEDIS standardf or diabetes was LDL-C <130 mg per dL throughout our study period. 25 Therefore, while we may comment on whether standards for LDL-C goal attainment among CHD patients werem et, we cannot make ad efinitive statement regarding physician adherence to clinical standards for lipid management in patients with diabetes. However,a survey of office-based physicians through 2004 indicated that the appearance of the 1998 ADA and 2001 ATPI II guidelines had little impact on trends in LDL-C testing and attainment of the <1 00 mg per dL goal. 33 Rates of LDL-C testing and goal attainment weret rending upwards for both CHD and diabetes since 1998 and wereapparently unaffected by ATPIII. 33 However,Y eet al. reported recently that the proportion of patients who received as tatin after aC HD hospitalization increased in each of 4y ears to an average 56% of patients in 2003. 34 Second, we defined continuous treatment broadly.C ontinuous treatment could have been as few as 2p harmacy claims (i.e., 2m onths of treatment) for al ipid-modifying drug in the first 12 months of follow up although the median was 7months and at least 1fill was required in each time period.
Third, the temporal relationship between the date of LDL-C testing and drug treatment within any given time period was not captured. It is possible, for example, that the LDL-C value was recorded prior to drug treatment in the first 6-month period (if this was either the only or the lowest LDL-C recording).

LDL-C Goal Attainment Among Patients Newly Diagnosed With Coronary Heart Disease or Diabetes in a Commercial HMO
Therefore, our data would tend to underestimate the number and proportion of patients at target LDL-C goal.
Fourth, lipid values performed in laboratories other than the single national provider or tests reported by physicians with a CPT code were not captured. Some patients could also have received lipid testing in the hospital, which would have made outpatient testing unnecessary for several months. However, due to this limitation, we did not calculate the number and proportion of patients that received LDL-C testing.
Fifth, these results may not be generalizable to other settings. This analysis was limited to 1 MCO located in the southeastern United States, and laboratory lipid values within the first 6 months after diagnosis were available for only 40% of the target population (4,676 of 11,552 patients), thereby limiting the sample for which lipid management and goal attainment could be assessed.
Sixth, we did not include information on patient race and socioeconomic status-factors reported previously to affect the likelihood of LDL-C testing among Medicare patients. 35 Last, we did not examine dyslipidemia versus LDL-C, and we cannot be certain that the lipid-lowering drug therapy was specifically used to treat elevated LDL-C. Finally, the use of claims data prohibited determination of the extent that patients could be splitting tablets. For example, a patient who received 40 mg

CONCLUSION
Only 27% of patients with CHD or diabetes patients who received a lipid test were at the LDL-C goal of < 100 mg per dL in the first 6 months after diagnosis. Among those who also received lipid-modifying drug therapy, only 39% were at goal in the first 6 months. The probability of goal attainment increased over the follow-up period, but for those who did not reach LDL-C goal in the first 6 months after diagnosis, goal attainment remained below 50% over the entire post-index period, averaging 26 months.